Healthcare Provider Details

I. General information

NPI: 1194193953
Provider Name (Legal Business Name): MARILYN BOOKER MA, LSC, LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 PLAINFIELD AVE NE STE 5
GRAND RAPIDS MI
49525-1010
US

IV. Provider business mailing address

4920 PLAINFIELD AVE NE STE 5
GRAND RAPIDS MI
49525-1010
US

V. Phone/Fax

Practice location:
  • Phone: 616-460-6448
  • Fax:
Mailing address:
  • Phone: 616-460-6448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number640101436
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberSC0000000793839
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: